Voluntary euthanasia: a utilitarian perspective

Belgium legalised voluntary euthanasia in 2002, thus ending the long isolation of the Netherlands as the only country in which doctors could openly give lethal injections to patients who have requested help in dying. Meanwhile in Oregon, in the United States, doctors may prescribe drugs for terminally ill patients, who can use them to end their life--if they are able to swallow and digest them. But despite President Bush's oft-repeated statements that his philosophy is to 'trust individuals to make the right decisions' and his opposition to 'distant bureaucracies', his administration is doing its best to prevent Oregonians acting in accordance with a law that its voters have twice ratified. The situation regarding voluntary euthanasia around the world is therefore very much in flux. This essay reviews ethical arguments regarding voluntary euthanasia and physician-assisted suicide from a utilitarian perspective. I shall begin by asking why it is normally wrong to kill an innocent person, and whether these reasons apply to aiding a person who, when rational and competent, asks to be killed or given the means to commit suicide. Then I shall consider more specific utilitarian arguments for and against permitting voluntary euthanasia.     

Euthanasia and the active-passive distinction

The author examines various claimed differences between active and passive euthanasia and, if there are differences, whether they are morally significant. He refutes arguments based on acting vs. not acting, intention, double effect, cause of death, and natural law theory. Reichenbach proposes that the most helpful distinction is the one between intentional killing (active euthanasia) and appropriate treatment for the dying or terminally ill (passive euthanasia). Significant moral difference, however, rests on the contention that intentional killing is always wrong and that, all else being equal, dying by natural means is intrinsically good, whereas dying by unnatural means is not.     

On the Moral Acceptability of Physician‐Assisted Dying for Non‐Autonomous Psychiatric Patients

Several authors have recently suggested that the suffering caused by mental illness could provide moral grounds for physician‐assisted dying. Yet they typically require that psychiatric‐assisted dying could come to question in the cases of autonomous, or rational, psychiatric patients only. Given that also non‐autonomous psychiatric patients can sometimes suffer unbearably, this limitation appears questionable. In this article, I maintain that restricting psychiatric‐assisted dying to autonomous, or rational, psychiatric patients would not be compatible with endorsing certain end‐of‐life practices commonly accepted in current medical ethics and law, practices often referred to as ‘passive euthanasia’.     

Bioethics and academic freedom

The author describes the events surrounding his attempts to lecture on the subject of euthanasia in West Germany in June 1989. Singer, who defends the view that active euthanasia for some newborns with handicaps may be ethically permissible, had been invited to speak to professional and academic groups. Strong public protests against Singer and his topic led to the cancellation of some of his engagements, disruptions during others, and harrassment of the German academics who had invited him to speak. These incidents and the subject of euthanasia became matters of intense national debate in West Germany, but there was little public or academic support for Singer's right to be heard. Singer argues that bioethics and bioethicists must have the freedom to challenge conventional moral beliefs, and that the events in West Germany illustrate the grave danger to that freedom from religious and political intolerance.     

The ethics of euthanasia: advocates' perspectives

The Netherlands is currently the only country in the world in which euthanasia is legally permissible. More specifically, Dutch law (briefly explained) allows that a doctor terminates the life of a patient of hers on his voluntary, well-considered and sustained request, if he is suffering unbearably and hopelessly. The aim of this paper is to reconstruct the Dutch debate on the moral permissibility of euthanasia so as to clarify and strengthen the various views that can be advanced in support of euthanasia. On the one view, The Pure Autonomy View (TPAV), the justification of euthanasia rests solely on the principle of respect for autonomy. That is, the reason for performing and permitting euthanasia is the patient's voluntary, well-considered and sustained, in one word: autonomous, request for euthanasia. On the alternative view, The Joint View (TJV), the principle of respect for autonomy and the principle of beneficence morally justify euthanasia together . That is, euthanasia is ethical if and partly because, since the patient is suffering unbearably and hopelessly, euthanasia is in his interest. According to this paper, there is no easy argument for one of these views rather than the other. Instead, as yet both TPAV and TJV seem inherently problematic. TPAV is unable to give a doctor a reason for performing euthanasia that appeals to her in her capacity as a doctor, such as relief of suffering. And TJV begs the question – for example, if a state were to legalize euthanasia on grounds of TJV, it would force the view upon its citizens that it may be in a person's interest to die.     

NARRATIVES OF ‘TERMINAL SEDATION’, AND THE IMPORTANCE OF THE INTENTION‐FORESIGHT DISTINCTION IN PALLIATIVE CARE PRACTICE

The moral importance of the ‘intention–foresight’ distinction has long been a matter of philosophical controversy, particularly in the context of end‐of‐life care. Previous empirical research in Australia has suggested that general physicians and surgeons may use analgesic or sedative infusions with ambiguous intentions, their actions sometimes approximating ‘slow euthanasia’. In this paper, we report findings from a qualitative study of 18 Australian palliative care medical specialists, using in‐depth interviews to address the use of sedation at the end of life. The majority of subjects were agnostic or atheistic. In contrast to their colleagues in acute medical practice, these Australian palliative care specialists were almost unanimously committed to distinguishing their actions from euthanasia. This commitment appeared to arise principally from the need to maintain a clear professional role, and not obviously from an ideological opposition to euthanasia. While some respondents acknowledged that there are difficult cases that require considered reflection upon one's intention, and where there may be some ‘mental gymnastics,’ the nearly unanimous view was that it is important, even in these difficult cases, to cultivate an intention that focuses exclusively on the relief of symptoms. We present four narratives of ‘terminal’ sedation – cases where sedation was administered in significant doses just before death, and may well have hastened death. Considerable ambiguities of intention were evident in some instances, but the discussion around these clearly exceptional cases illustrates the importance of intention to palliative care specialists in maintaining their professional roles.     

Killing, letting die and moral perception

There are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro-euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism.     

THE DEAD DONOR RULE,VOLUNTARY ACTIVE EUTHANASIA,AND CAPITAL PUNISHMENT

We argue that the dead donor rule, which states that multiple vital organs should only be taken from dead patients, is justified neither in principle nor in practice. We use a thought experiment and a guiding assumption in the literature about the justification of moral principles to undermine the theoretical justification for the rule. We then offer two real world analogues to this thought experiment, voluntary active euthanasia and capital punishment, and argue that the moral permissibility of terminating any patient through the removal of vital organs cannot turn on whether or not the practice violates the dead donor rule. Next, we consider practical justifications for the dead donor rule. Specifically, we consider whether there are compelling reasons to promulgate the rule even though its corresponding moral principle is not theoretically justified. We argue that there are no such reasons. In fact, we argue that promulgating the rule may actually decrease public trust in organ procurement procedures and medical institutions generally – even in states that do not permit capital punishment or voluntary active euthanasia. Finally, we examine our case against the dead donor rule in the light of common arguments for it. We find that these arguments are often misplaced – they do not support the dead donor rule. Instead, they support the quite different rule that patients should not be killed for their vital organs.     

A Survey of Veterinarians’ Attitudes toward Euthanasia of Companion Animals in Japan

This study investigated veterinarians’ attitudes toward euthanasia of companion animals in Japan. A nationwide survey was conducted with 932 veterinarians in small animal practices. It examined the number of times they administered euthanasia, their moral criteria for choosing euthanasia for animals, and their behavioral criteria for suggesting euthanasia to owners. According to the data analyses, on average the veterinarians administered euthanasia 2.48 times a year. For many veterinarians, two conditions were necessary to justify euthanasia for animals: “the animals are incurable and suffering” and “the owners request to euthanize the animals.” In the absence of either condition, the veterinarians were inclined to disapprove of choosing euthanasia. If the owners requested further treatment, 67% showed clear disapproval of choosing euthanasia for animals with serious medical conditions. Meanwhile, more than 76% showed clear disapproval of euthanizing healthy animals when the owners requested it. These results indicate that the owners’ request takes precedence over the animals’ condition for suffering animals, but not for healthy animals. For animals with serious medical conditions, 56% of the veterinarians answered that they would or might suggest euthanasia to the owners even though the owners requested further treatment. In this situation, for some veterinarians, the animals’ condition rather than the owners’ request might become a determinant in suggesting euthanasia to owners, even if their moral judgments were against choosing euthanasia for the animals. A decrease in the owners’ or the animals’ quality of life and the owners’ inability to pay were not primary factors in choosing or suggesting euthanasia. Having an experience of euthanizing their own animals was a key factor for the veterinarians which increased not only the number of times they administered euthanasia but also the degree of their moral approval of choosing euthanasia and their behavioral willingness to suggest it to owners.     

Public attitudes toward euthanasia and suicide for terminally ill persons: 1977 and 1996

This study replicates Singh's (1979) "classic" examination of correlates of euthanasia and suicide attitudes. The purposes of the current study were to assess (1) changes in public attitudes toward these voluntary termination of life practices, and (2) changes in the effects on attitudes of selected independent variables. I found Americans' approval of both euthanasia and suicide in 1996 to be higher than that in 1977. The increase in the approval of suicide, however, far outstripped that of euthanasia. Results of OLS regressions indicated that race, religious commitment, religious attendance, political identification, and suicide approval were statistically significant predictors of euthanasia approval. Only religious attendance and euthanasia approval were statistically significant predictors of suicide approval in both 1977 and 1996. The findings regarding euthanasia approval support those of Singh (1979); those regarding suicide approval do not. Triangulation of methods in future research is necessary to illuminate other aspects of these multifaceted issues.     

Execution by lethal injection, euthanasia, organ-donation and the proper goals of medicine

In a recent issue of this journal, David Silver and Gerald Dworkin discuss the physicians' role in execution by lethal injection. Dworkin concludes that discussion by stating that, at that point, he is unable to think of an acceptable set of moral principles to support the view that it is illegitimate for physicians to participate in execution by lethal injection that would not rule out certain other plausible moral judgements, namely that euthanasia is under certain conditions legitimate and that organ-donation surgery is sometimes permissible. This article draws attention to some problems in the views of Silver and Dworkin and suggests moral principles which support the three moral views just mentioned.     

"Post-residency disease" and the medical self: identity, work, and health care among doctors who become patients

Doctors who become patients due to serious illnesses face many challenges related to issues of identity, work, and professionalism. In-depth interviews with such doctors reveal the complex ways in which illness threatens identity in these professionals. In comparison with "medical student's disease," these doctors now exhibit "post-residency disease"-minimizing physical symptoms that are in fact present, leading to decreases in care sought. Doctors often feel they are somehow invulnerable to disease and have to remain strong, not burdening others. Many describe themselves as "workaholics," which can prove to be a double-edged sword, posing problems as well as providing benefits. This professional commitment could interfere with preventive health behaviors and with "practicing what they preach." Some view their illness with their "medical self" - as if they were a physician observing another patient rather than themselves. These doctors often support their approach by choosing a colleague as a doctor who will not challenge them, thereby establishing a "denial system" as opposed to a support system. These doctor-patients confront difficult issues of how much their physicianhood is an identity or an activity, illustrating the intricate relationships and tensions between work, identity, professionalism, and health in contemporary medicine.     

MORAL FICTION OR MORAL FACT? THE DISTINCTION BETWEEN DOING AND ALLOWING IN MEDICAL ETHICS

Opponents of physician‐assisted suicide (PAS) maintain that physician withdrawal‐of‐life‐sustaining‐treatment cannot be morally equated to voluntary active euthanasia. PAS opponents generally distinguish these two kinds of act by positing a possible moral distinction between killing and allowing‐to‐die, ceteris paribus. While that distinction continues to be widely accepted in the public discourse, it has been more controversial among philosophers. Some ethicist PAS advocates are so certain that the distinction is invalid that they describe PAS opponents who hold to the distinction as in the grip of ‘moral fictions’. The author contends that such a diagnosis is too hasty. The possibility of a moral distinction between active euthanasia and allowing‐to‐die has not been closed off by the argumentative strategies employed by these PAS advocates, including the contrasting cases strategy and the assimilation of doing and allowing to a common sense notion of causation. The philosophical debate over the doing/allowing distinction remains inconclusive, but physicians and others who rely upon that distinction in thinking about the ethics of end‐of‐life care need not give up on it in response to these arguments.     

THE NON-IDENTITY PROBLEM AND GENETIC HARMS – THE CASE OF WRONGFUL HANDICAPS

The Human Genome Project will produce information permitting increasing opportunities to prevent genetically transmitted harms, most of which will be compatible with a life worth living, through avoiding conception or terminating a pregnancy. Failure to prevent these harms when it is possible for parents to do so without substantial burdens or costs to themselves or others are what J call "wrongful handicaps". Derek Parfit has developed a systematic difficulty for any such cases being wrongs — when the harm could be prevented only by preventing the existence of the individual who would have a worthwhile life even with the handicap, then bringing him into existence with the handicap does not make him worse off and so does not wrong him. I argue that a non "person-affecting" principle requiring the avoidance of suffering and limited opportunity correctly accounts for cases of wrongful handicaps without requiring that the individuals with the handicap have been made worse off and therefore wronged. It is an advantage, not a difficulty, of this account that it does not imply that the person with the handicap has been wronged or is a victim with a special moral complaint.     

The non-identity problem and genetic harms -- the case of wrongful handicaps

The Human Genome Project will produce information permitting increasing opportunities to prevent genetically transmitted harms, most of which will be compatible with a life worth living, through avoiding conception or terminating a pregnancy. Failure to prevent these harms when it is possible for parents to do so without substantial burdens or costs to themselves or others are what I call "wrongful handicaps". Derek Parfit has developed a systematic difficulty for any such cases being wrongs -- when the harm could be prevented only by preventing the existence of the individual who would have a worthwhile life even with the handicap, then bringing him into existence with the handicap does not make him worse off and so does not wrong him. I argue that a non "person-affecting" principle requiring the avoidance of suffering and limited opportunity correctly accounts for cases of wrongful handicaps without requiring that the individuals with the handicap have been made worse off and therefore wronged. It is an advantage, not a difficulty, of this account that it does not imply that the person with the handicap has been wronged or is a victim with a special moral complaint.     

Illness, suffering and voluntary euthanasia

It is often accepted that we may legitimately speak about voluntary euthanasia only in cases of persons who are suffering because they are incurably injured or have an incurable disease. This article argues that when we consider the moral acceptability of voluntary euthanasia, we have no good reason to concentrate only on persons who are ill or injured and suffering.     

End of Life Care for Patients Dying of Stroke: A Comparative Registry Study of Stroke and Cancer

Background

Although stroke is a significant public health challenge and the need for palliative care has been emphasized for these patients, there is limited data on end-of-life care for patients dying from stroke.

Objective

To study the end-of-life care during the last week of life for patients who had died of stroke in terms of registered symptom, symptom management, and communication, in comparison with patients who had died of cancer.

Design

This study is a retrospective, comparative registry study.

Methods

A retrospective comparative registry study was performed using data from a Swedish national quality register for end-of-life care based on WHO`s definition of Palliative care. Data from 1626 patients who had died of stroke were compared with data from 1626 patients who had died of cancer. Binary logistic analyses were used to calculate odds ratios, with 95% CI.

Results

Compared to patients who was dying of cancer, the patients who was dying of stroke had a significantly higher prevalence of having death rattles registered, but a significantly lower prevalence of, nausea, confusion, dyspnea, anxiety, and pain. In addition, the stroke group had significantly lower odds ratios for health care staff not to know whether all these six symptoms were present or not. Patients who was dying of stroke had significantly lower odds ratio of having informative communication from a physician about the transition to end-of-life care and of their family members being offered bereavement follow-up.

Conclusions

The results indicate on differences in end-of-life care between patients dying of stroke and those dying from cancer. To improve the end-of-life care in clinical practice and ensure it has consistent quality, irrespective of diagnosis, education and implementation of palliative care principles are necessary.     

MORAL FICTIONS AND MEDICAL ETHICS

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life‐sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life‐sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life‐sustaining treatment in order to bring accepted end‐of‐life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end‐of‐life decisions is radically mistaken.     

The dangers of euthanasia and dementia: how Kantian thinking might be used to support non-voluntary euthanasia in cases of extreme dementia

Some writers have argued that a Kantian approach to ethics can be used to justify suicide in cases of extreme dementia, where a patient lacks the rationality required of Kantian moral agents. I worry that this line of thinking may lead to the more extreme claim that euthanasia is a proper Kantian response to severe dementia (and similar afflictions). Such morally treacherous thinking seems to be directly implied by the arguments that lead Dennis Cooley and similar writers to claim that Kant might support suicide. If rationality is the only factor in valuing a human life, then the loss of that rationality (however such loss might be defined) would allow us to use essentially utilitarian thinking in order to support non-voluntary euthanasia, since the patients themselves would no longer be moral agents that demand respect.     

Public reasoning about voluntary assisted dying: An analysis of submissions to the Queensland Parliament,Australia

The use of voluntary assisted dying as an end‐of‐life option has stimulated concerns and debates over the past decades. Although public attitudes towards voluntary assisted dying (including euthanasia and physician‐assisted suicide) are well researched, there has been relatively little study of the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. Using a mix of computational textual mining techniques, keyword study and qualitative thematic coding to analyse public submissions to a parliamentary inquiry into voluntary assisted dying in Australia, this study critically examines the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. The analysis identified complex and potentially contradictory ethical principles being invoked on both sides of the debate. These findings deepen our understanding of the moral basis of public reasoning about end‐of‐life matters and will help to inform future discussions on policy and law reform. The findings underscore the importance of sound normative reasoning and the use of caution when interpreting opinion polls to inform policy.